Model of Care Scores

Humana Benefit Plan Of Illinois, Inc. Dual-Eligible

H5525 | 2 Years | Dual-Eligible

Overall Score
81.67 %
MOC 1

MOC 1

4 out of 8 pts
MOC 2

MOC 2

18 out of 20 pts
MOC 3

MOC 3

7 out of 12 pts
MOC 4

MOC 4

20 out of 20 pts

Standards and Scoring Details

MOC 1: Description of SNP Population (General Population)

Identification and a comprehensive description of the SNP-specific population are integral components of the model of care (MOC). All elements in this standard depend on a complete population description that addresses the full continuum of care of current and potential SNP beneficiaries, including end-of-life needs and considerations (if relevant).

SNPs must include a complete description of specially tailored services for beneficiaries considered especially vulnerable (refer to Element 1B), using specific terms and details (e.g., members with multiple hospital admissions within three months, “medication spending above $4,000”).

Scoring Details for this Plan

Element A: Description of Overall SNP Population Score: 3 / 4
The organization’s MOC description of its target SNP population must:
Describe how the health plan staff will determine, verify and track eligibility of SNP beneficiaries.
Describe the social, cognitive and environmental factors, living conditions and co-morbidities associated with the SNP population.
Identify and describe the medical and health conditions impacting SNP beneficiaries.
Define the unique characteristics of the SNP population served.
Element B: Subpopulation—Most Vulnerable Beneficiaries Score: 1 / 4
The organization must have a complete description of the specially tailored services it provides to its most vulnerable members that:
Defines and identifies the most vulnerable beneficiaries within the SNP population and provides a complete description of specially tailored services for such beneficiaries.
Explains how the average age, gender, ethnicity, language barriers, deficits in health literacy, poor socioeconomic status, as well as other factors, affect the health outcomes of the most vulnerable beneficiaries.
Illustrates a correlation between the demographic characteristics of the most vulnerable beneficiaries and their unique clinical requirements.
Identifies and describes established relationships with partners in the community to provide needed resources.

MOC 2: Care Coordination

Care coordination helps ensure that SNP beneficiaries’ health care needs, preferences for health services and information sharing across health care staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, high-quality patient services (including services furnished outside the SNP’s provider network) that ultimately lead to improved health care outcomes.

The following MOC elements are essential components to consider in the development of a comprehensive care coordination program; no element must be interpreted as being of greater importance than any other. Taken together, all five elements must address the SNP’s care coordination activities comprehensively.

Scoring Details for this Plan

Element A: SNP Staff Structure Score: 4 / 4
The organization’s MOC must:
Describe the administrative staff’s roles and responsibilities, including oversight functions.
Describe the clinical staff’s roles and responsibilities, including oversight functions.
Describe how staff responsibilities coordinate with the job title.
Describe contingency plans used to address ongoing continuity of critical staff functions.
Describe how the organization conducts initial and annual MOC training for its employed and contracted staff.
Describe how the organization documents and maintains training records as evidence that employees and contracted staff completed MOC training.
Describe actions the organization takes if staff do not complete the required MOC training.
Element B: Health Risk Assessment Tool (HRAT) Score: 4 / 4
The organization’s MOC includes a clear and detailed description of the policies and procedures for completing the HRAT that addresses:
How the organization uses the HRAT to develop and update the Individualized Care Plan (ICP) for each beneficiary (Element 2C).
How the organization disseminates the HRAT information to the Interdisciplinary Care Team (ICT) and how the ICT uses that information (Element 2D).
How the organization conducts the initial HRAT and annual reassessment for each beneficiary.
The detailed plan and rationale for reviewing, analyzing and stratifying (if applicable), the HRA results.
Element C: Individualized Care Plan (ICP) Score: 4 / 4
The description of the organization’s ICP must include:
The essential components of the ICP.
The process to develop the ICP, including how often the ICP is modified as beneficiaries’ health care needs change.
The personnel responsible for development of the ICP, including how beneficiaries and/or caregivers are involved.
How the ICP is documented, updated and where it is maintained.
How updates and modifications to the ICP are communicated to the beneficiary and other stakeholders.
Element D: Interdisciplinary Care Team (ICT) Score: 3 / 4
The organization’s MOC must describe the critical components of the ICT, including:
How the organization determines the composition of ICT membership.
How the roles and responsibilities of the ICT members (including beneficiaries and/or caregivers) contribute to the development and implementation of an effective interdisciplinary care process.
How ICT members contribute to improving the health status of SNP beneficiaries.
How the SNP’s communication plan to exchange beneficiary information occurs regularly within the ICT, including evidence of ongoing information exchange.
Element E: Care Transition Protocols Score: 3 / 4
The organization’s MOC describes the following care transition protocols:
How the organization uses care transition protocols to maintain continuity of care for SNP beneficiaries.
The personnel responsible for coordinating the care transition process.
How the organization transfers elements of the beneficiary’s ICP between health care settings when the beneficiary experiences an applicable transition in care.
How beneficiaries have access to personal health information to facilitate communication with providers in other healthcare settings.
How beneficiaries and/or caregivers will be educated about the beneficiary’s health status to foster appropriate self-management activities.
How the beneficiaries and/or caregivers are informed about the point of contact throughout the transition process.

MOC 3: Provider Network

The SNP provider network is a network of health care providers who are contracted to provide health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully describes and implements the following elements for their SNP provider networks.

Scoring Details for this Plan

Element A: Specialized Expertise Score: 2 / 4
The organization must establish a provider network with specialized expertise that describes the following components of the network:
How providers with specialized expertise correspond to the target population identified in MOC 1.
How the SNP oversees its provider network facilities and oversees that its providers are competent and have active licenses.
How the SNP documents, updates and maintains accurate provider information.
How providers collaborate with the ICT and contribute to a beneficiary’s ICP to provide necessary specialized services.
Element B: Use of Clinical Practice Guidelines and Care Transition Protocols Score: 2 / 4
The organization must oversee how network providers use evidence-based medicine, when appropriate, by:
Explaining the processes for monitoring how network providers utilize appropriate clinical practice guidelines and nationally recognized protocols appropriate to each SNP’s target population.
Identifying challenges where the use of clinical practice guidelines and nationally recognized protocols need to be modified or are inappropriate for specific vulnerable SNP beneficiaries.
Providing details regarding how decisions to modify clinical practice guidelines or nationally recognized protocols are made, incorporated into the ICP, communicated to the ICT and acted upon by the ICT.
Describing how SNP providers maintain continuity of care using the care transition protocols outlined in MOC 2, Element E.
Element C: MOC Training for the Provider Network Score: 3 / 4
The organization’s description of oversight of provider network training on the MOC must include:
Requiring initial and annual training for network providers and out-of-network providers seen by beneficiaries on a routine basis.
Documenting evidence that the organization makes available and offers training on the MOC to network providers.
Explaining challenges associated with the completion of MOC training for network providers.
Taking action when the required MOC training is deficient or has not been completed.

MOC 4: MOC Quality Measurement and Performance Improvement

The goal of performance improvement and quality measurement is to improve the SNP’s ability to deliver high-quality health care services and benefits to its SNP beneficiaries. Achievement of this goal may be the result of increased organizational effectiveness and efficiency through incorporation of quality measurement and performance improvement concepts that drive organizational change.

The leadership, managers and governing body of a SNP organization must have a comprehensive quality improvement program in place to measure its current level of performance and determine if organizational systems and processes must be modified, based on performance results.

Scoring Details for this Plan

Element A: MOC Quality Performance Improvement Plan Score: 4 / 4
The organization must develop a MOC quality performance improvement plan that:
Describes the overall quality improvement plan and how the organization delivers or provides for appropriate services to SNP beneficiaries, based on their unique needs.
Describes specific data sources and performance and outcome measures used to continuously analyze, evaluate and report MOC quality performance.
Describes how its leadership, management groups, other SNP personnel and stakeholders are involved with the internal quality performance process.
Describes how SNP-specific measureable goals and health outcomes objectives are integrated in the overall performance improvement plan, as described in MOC 4, Element B.
Element B: Measureable Goals and Health Outcomes for the MOC Score: 4 / 4
The organization must identify and clearly define measureable goals and health outcomes for the MOC and:
Identify and define the measurable goals and health outcomes used to improve the health care needs of SNP beneficiaries.
Identify specific beneficiary health outcome measures used to measure overall SNP population health outcomes at the plan level.
Describe how the SNP establishes methods to assess and track the MOC’s impact on SNP beneficiaries’ health outcomes.
Describe the processes and procedures the SNP will use to determine if health outcome goals are met.
Describe the steps the SNP will take if goals are not met in the expected time frame.
Element C: Measuring Patient Experience of Care (SNP Member Satisfaction) Score: 4 / 4
The organization’s MOC must address the process of measuring SNP member satisfaction by:
Describing the specific SNP survey used.
Explaining the rationale for the selection of a specific tool.
Describing how results of patient experience surveys are integrated into the overall MOC performance improvement plan.
Describing steps taken by the SNP to address issues identified in survey responses.
Element D: Ongoing Performance Improvement Evaluation of the MOC Score: 4 / 4
The organization’s MOC description must describe:
How the organization will use the results of the quality performance indicators and measures to support ongoing improvement of the MOC.
How the organization will use the results of the quality performance indicators and measures to continually assess and evaluate quality.
The organization’s ability for timely improvement of mechanisms for interpreting and responding to lessons learned through the MOC performance evaluation.
How the performance improvement evaluation of the MOC will be documented and shared with key stakeholders.
Element E: Dissemination of SNP Quality Performance Related to the MOC Score: 4 / 4
The organization must address the process for communicating its quality improvement performance by:
Describing how performance results and other pertinent information are shared with multiple stakeholders.
Stating the scheduled frequency of communications with stakeholders.
Describing the methods for ad hoc communication with stakeholders.
Identifying the individuals responsible for communicating performance updates in a timely manner.